The severity of pruritus is important in the decision to proceed with surgery. It forms nonabsorbable Artesunate micelles with the bile acids in the intestines and prevents bile acids from entering the enterohepatic cycle. Cholestramine should be taken at least 1 hour before or 4C6 hours after meals, 1C4 gr/day. This drug induces liver enzyme activity and increases bilirubin excretion. In patients with reduced serum bilirubin levels, pruritus also regresses. Rifampicin Rifampicin acts by upregulating detoxification enzymes and export pumps through farnesoid X receptor (FXR) dependent mechanisms. Rifampicin indirectly induces hydroxylation of bile salts which are further glucuronidated and excreted in urine. It also induces conjugation and excretion of bilirubin through uridine diphosphate (UDP)-glucuronosyl transferase.19 It is used 5C10 mg/kg/day. Phenobarbital Phenobarbital, is used to induce CYP/CYP450 system in the treatment of newborn hyperbilirubinemia and chronic cholestasis with low bilirubin levels at a dose of 3C10 mg/kg/day. 4-phenylbutyrate Hasegawa et al21 evaluated the therapeutic potency of 4-phenylbutyrate in three patients with PFIC1 and observed that at a dosage of 350 or 500 mg/kg/day per orally significantly relieved the intractable itch. Naoi et al22 evaluated the effect of 4-phenylbutyrate in one patient with PFIC-2 and concluded that in patients with decreased cell-surface expression of BSEP among Artesunate PFIC-2s, 4-phenylbutyrate (4PB) therapy has partially restored BSEP expression at the canalicular membrane, significantly improved liver tests and pruritus at a dosage of 500 mg/kg/day. Other drugs Antihistaminic agents, opiate antagonists, ondansetron, steroids, propofol, and carbamazepine are part of the additional medical therapy options. Nasobiliary drainage Nasobiliary drainage is the nonsurgical, temporary diversion of bile through an endoscopically launched nasobiliary drain. The risk of pancreatitis should not be overlooked. Surgical management Intractable pruritus despite medical treatment, growth failure and nutritional deficiencies necessitate surgery. Pruritus is assessed according to the Whitington level. The severity of pruritus is definitely important in the decision to continue with surgery. There is epidermal bleeding at grade four according to this level. Biliary diversion methods aim to interrupt the enterohepatic recirculation of bile salts via an anastomosis of the biliary tract to the intestines (internal drainages) or to the skin (external Artesunate diversions). Therefore, accumulating extra serum bile salts decrease, biliary acid composition changes, pruritus regresses, progression to cirrhosis delays. Partial biliary diversions have been used successfully in many individuals with PFIC-1 and 2, who do not respond to medical therapy and are as yet not candidates for liver transplant.23 Diversions help to improve liver functions, growth, liver histology, reduce progression of fibrosis and extend the time interval before liver transplantation in the majority of individuals with PFIC-1 and 2. If the individuals have not developed cirrhosis at the Artesunate time of surgery treatment, the results are even more satisfying, consequently biliary diversions should be offered early before development of cirrhosis. Partial external biliary diversions (PEBD) The PEBD process, once explained by Whitington et al,24 entails use of a 10C15 cm jejunal conduit between the fundus of the gallbladder and abdominal pores and skin where a long term stoma is created. Diversion of bile interrupts the enterohepatic blood circulation of bile salts, diminishes subsequent reuptake and decreases the pool of bile salts.24C29 PEBD has gained popularity over the last few years. So far additional modifications of the conduit between gall bladder and pores and skin have been understood to be the use of a switch of gall bladder wall (cholecystostomy), appendix (cholecystoappen-dicocutaneostomy) or ileum (cholecystoileocutaneostomy). Cholecystostomy may seem practical but keeping an properly watertight stoma is definitely challenging and this CSF2RB technique has a high risk of cholangitis. PEBD is used extensively as the 1st collection surgery treatment in PFIC-1 and 2 individuals. Many retrospective review reports of individual Artesunate centers state that pruritus has been relieved, liver chemistry and liver function tests, serum lipid levels and growth are improved in most individuals.29,30 Many studies possess outlined regression of histological abnormalities in the liver after PEBD and Arnell et al29.
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