Dr. Keith Roach: PSC is serious diagnosis, requires confirmation
Dear Dr. Roach: I am a 58-year-old male. Two years ago, after a routine physical, my bloodwork came back abnormal for liver function, especially the alkaline phosphatase. Prior to this, my bloodwork numbers were normal. Since then, I have had liver ultrasounds, an MRI and even a liver biopsy. They showed some slight inflammation of the liver but nothing major; it just seems the bloodwork numbers are off. I’m 5 feet, 9 inches tall and weigh 175 pounds. I’m still very active and in good health except for this liver function number. I do have ulcerative colitis, and I’m taking Lialda. My doctor thinks I have primary sclerosing cholangitis, and I’m currently taking ursodiol (Actigall). She does not really know if PSC is what I have, but feels we need to try this. I have never been a heavy drinker, and in the past two years I’ve cut back even more on my beer drinking to maybe one or two, twice a week after golf. I totally stopped drinking for a couple of months, but it made no difference in my blood test results. I get a full metabolic blood panel every six to eight weeks, but the numbers don’t change much. What can I do?
Dear L.S.: Primary sclerosing cholangitis is a chronic, progressive, inflammatory disease of the liver. It is strongly associated with inflammatory bowel disease, especially ulcerative colitis, and it is more common in men. The diagnosis usually is made by cholangiogram, which is most often done now via MRI. Liver biopsy is sometimes also necessary. I am concerned that your doctor isn’t sure of the diagnosis. It might be appropriate to get your MRI and liver biopsy reviewed by an expert, since this is a very serious diagnosis and there are other conditions that PSC may be confused with.
PSC typically progresses over 10 to 12 years to severe liver disease, and when the liver disease becomes serious, liver transplantation becomes the best treatment option. Although some treatments, especially ursodeoxycholic acid (Actigall) are commonly tried and might reduce the abnormal blood levels, there is no clear evidence that they slow down the progression of the disease. Alcohol may speed up progression, so I would recommend complete cessation.
One additional point is that there are some complications that may occur with PSC, the most worrisome of which is cholangiocarcinoma (cancer of the bile duct). Many experts in PSC recommend periodic screening, although the best method for this is not clear.
There are many educational resources and support groups for PSC. One is found at pscpartners.org.
Dear Dr. Roach: A friend from Thailand with prostate cancer treated with radical surgery recently came to the U.S. to be evaluated for an increasing PSA level, up to 0.65, and losing weight. The doctors here can’t find anything wrong with him. Have you heard of this?
Dear C.P.: A rising PSA level after surgery almost always means recurrence of disease, which can be either in the area of surgery or at distant sites, usually in the bone.
Unfortunately, even the most sensitive techniques sometimes cannot find the areas of cancer in the very earliest stages. There are experimental drugs (such as monoclonal antibodies) that can find recurrent disease earlier than standard imaging tests, and it might be worthwhile having your friend look at some ongoing studies.
Clinicaltrials.gov is a good place to start.
Email questions to ToYourGoodHealth@med.cornell.edu.