DOCTORS PANEL QUESTIONS & ANSWERS

We wish to thank all the members on our Doctors Panel, for giving us their time answering PBCers questions.  We greatly appreciate all they do for us.

The following questions were answered by: 
Howard Worman, M.D.
Division of Digestive and Liver Diseases
Departments of Medicine and of Anatomy and Cell Biology
College of Physicians & Surgeons
Columbia University
New York, NY 10032


Question 1
Does PBC cause overproduction of bile? If so, should PBCers avoid foods that stimulate bile production? Some of these are very healthful such as kale and other bitter greens. Please explain.

Answer 1
I am not aware of PBC causing "overproduction of bile."  The main problem in PBC is cholestasis, or decreased bile flow in the small bile ducts within the liver.  There are no data or reasons to believe that individuals with PBC should avoid foods such as kale or bitter greens.


Question 2
What can you tell me about plasmaphresis?  In your experience does it help the itching?  How many treatments are necessary before relief is obtained?  Do you know what the risks involved are?

Answer 2
In plasmapheresis, blood is removed from the body and the fluid (plasma) is separated from the cells.  The plasma can then be passed over a column to remove certain substances.  Passing the plasma over a charcoal column would remove certain substances, and it has been hypothesized that doing this in subjects with PBC who itch could remove substances responsible for the itching.  It has been tried in some patients who have reported that it helped the itching.  However, controlled, randomized studies are lacking showing that it is effective.  So I cannot answer your questions regarding "does it help the itching" and "how many treatments are necessary before relief is obtained."  Plasmapheresis for itching in PBC is currently experimental and should be studied further.  Some risks of plasmapheresis include loss of blood calcium, replacement with plasma that may contain infectious agents, allergic reactions, bleeding, abnormal blood coagulation during the procedure and body fluid balance problems.  


Question 3
What class of antibiotics would you recommend for bacterial infections that are least damaging to the liver?

Answer 3
Only a doctor who obtains a complete history, examines the patient and knows the identity of or has an idea about infecting bacteria can recommend appropriate antibiotics.  Antibiotics per se are not "damaging to the liver."  Idiosyncratic (unpredictable) liver damage can occur with some antibiotics in any person and having PBC does not make this more or less probable. 


Question 4
Are Questran & Cholestyramine the same?  Could you explain the difference and how they help the itching.

Answer 4
They are the same.  Questran (capital "Q") is a proprietary name (manufactured by Par Pharmaceutical, Inc. in the US and sold as Questran and Questran Light) and cholestyramine (lower case "c") is a generic name.  Cholestyramine resin combines with the bile acids in the intestine to form an insoluble complex excreted in the feces.  This may lead to decreased bile acids in the skin and decreased itching.  It may also bind to and lead to excretion of other substances responsible for itch.


Question 5
Do you recommend your patients get flu and pneumonia shots?  What about Hepatitis A & B shots?  I plan on traveling out of the country and a friend suggested I get the Hepatitis shots.

Answer 5
The United States Centers for Disease Control and Prevention (CDC) provides recommendations about who should get influenza vaccine ("flu shots"); see

http://www.cdc.gov/ncidod/dhqp/id_influenza_vaccine.html

Many individuals with PBC will fall into some of those categories.  Therefore, they should be vaccinated.  Importantly, anyone who wants to decrease the risk of getting influenza and does not have a contraindication can receive the vaccination.

The CDC also provides recommendations regarding who should receive pneumococcal vaccine ("pneumonia shots"); see:

http://wonder.cdc.gov/wonder/prevguid/m0042325/m0042325.asp

The CDC also provides vaccination recommendations for potential travelers to different countries; see:

http://www.cdc.gov/nip/webutil/menu-travelers.htm#Vaccinations). 

Potential travelers should review this and discuss it with their doctors.

To summarize a few things:

There are no specific recommendations about these vaccinations for individuals with PBC.  Anyone who wants to be vaccinated for hepatitis A, hepatitis B and, each year, for influenza ("flu") can be unless there is a specific contraindication.  Many older individuals may be immune to hepatitis A and not know it; their doctors can check for that by blood testing.  It is recommended that all children in the US and adults at increased risk of infection receive hepatitis B virus vaccine. 

It is probably a good idea for individuals with chronic liver disease to be vaccinated against hepatitis A and B.  While there are no specific data from subjects with PBC, some studies have suggested that this is beneficial for individuals with other chronic liver diseases. 

The CDC recommends that individuals with cirrhosis, which some people with PBC will have, should obtain pneumococcal vaccine.  Although cirrhosis is not a specific recommendation for influenza vaccination, CDC recommends the vaccine for individuals "who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases, renal dysfunction, hemoglobinopathies, or immunosuppression."  Some individuals with complications of cirrhosis would fall into this category.  So patients with "advanced PBC" (cirrhosis) may require influenza and pneumococcal vaccination.


Question 6
If a person has portal hypertension without varicies is it unlikely they will develop varicies or does it just depend on the individual?  What exactly causes the varicies and what are the symptoms?  Does any type of food affect varicies such as potatoe chips?

Answer 6
Varices (varicose veins) are caused by increased pressure in the veins of the esophagus, stomach and rectum (and a few other places) where the portal (gut and liver) and systemic circulations meet.  Esophageal and gastric varices usually do not cause any symptoms until they bleed, which is usually life-threatening and requires emergent medical care.  Rectal varices can cause hemorrhoids.   Varices are caused by increased portal blood pressure (portal hypertension).  However, it is not clear why some individuals with portal hypertension have varices and other do not.  It is also not clear why some individuals get them in some places and not others.  There are no data to suggest that any foods affect varices or their risk of bleeding. 

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