Primary Biliary Cholangitis

What is Primary Biliary Cholangitis?

Primary biliary cholangitis (PBC) is an autoimmune disease that slowly destroys the small bile ducts inside the liver, which leads to bile building up (cholestasis) and, over years, can cause scarring and cirrhosis.^[1] It was formerly called primary biliary cirrhosis and mainly affects women between about 40 and 70 years of age.^[2]

Common symptoms

Many people have no symptoms when PBC is found, often because a blood test shows abnormal liver enzymes. When symptoms appear, fatigue and itching are the most burdensome and can seriously affect quality of life.^{[2, 3]}

• Persistent tiredness that does not improve with rest
• Itching (pruritus), often worse at night
• Dry eyes and dry mouth, which can occur when PBC overlaps with Sjögren's disease
• Yellowing of the skin and eyes (jaundice) in later disease
• Discomfort in the upper right abdomen

Causes and risk factors

The cause is not fully known. PBC appears to occur in people with a genetic susceptibility who are exposed to environmental triggers, including certain chemicals, smoking and changes in the gut microbiome.^[2] PBC is most common in women and in people over 50.^[3]

How it is diagnosed and treated conventionally

PBC is usually diagnosed when blood tests show a cholestatic pattern, especially a raised alkaline phosphatase, together with antimitochondrial antibodies.^[3] Imaging may be used to exclude other bile duct problems, and a biopsy is needed only in selected cases.

Treatment is lifelong and supervised by a physician. Ursodeoxycholic acid is the standard first treatment, and those with an incomplete response or intolerance may be offered second-line drugs.^{[3, 4]} Itching has its own stepwise treatments, and some drugs shown to help include bezafibrate and rifampicin.^{[5, 6]} Liver transplantation is reserved for advanced disease.^[6]

Why Primary Biliary Cholangitis calls for a whole-person approach

PBC is not only a liver problem. The immune system, the gut, and the symptoms that follow all shape how a person lives with it.^[2] The medical team treats the disease itself; supportive care can look at the burden of symptoms around it.

Fatigue, itching and poor sleep tend to reinforce each other, and they often matter more to daily life than the blood tests do. Reducing these burdens is an accepted treatment goal alongside controlling the disease.^[2]

Itching

Cholestatic itch is common in PBC, and its cause is still poorly understood. Researchers think chemicals that build up in cholestasis act on itch nerve fibers in the skin.^{[5, 6]}

Fatigue

Fatigue is the most common and often the most disabling symptom, and treatment options are limited.^{[2, 3]} Poor sleep, low mood and itching can add to it.

The immune system and the gut

PBC arises from an immune attack on bile duct cells, and the diversity of gut bacteria is reduced in people with PBC.^[2] This is why researchers are interested in the gut, although no gut-directed complementary therapy has been shown to change the course of PBC.

Other autoimmune conditions

PBC often overlaps with other autoimmune diseases, such as Sjögren's disease, which causes dry eyes and mouth.^[3] Each of these needs its own medical review.

Acupuncture as supportive care in Primary Biliary Cholangitis

What the research shows

A PubMed search found no clinical trials of acupuncture in people with PBC, so we cannot say that it helps the disease or its symptoms in PBC. Anything below comes from studies of other conditions and may not carry over.

For fatigue, a 2019 meta-analysis of 16 trials in chronic fatigue syndrome found acupuncture more effective than sham acupuncture in a pooled analysis of four trials, but most studies were of low quality and the authors reached no firm conclusion.^[7] For sleep, a review of 24 trials in insomnia included a meta-analysis of 15 trials that suggested acupuncture improved sleep quality scores more than medication after about three weeks, although results varied widely between studies.^[8]

For itching, the best data are in kidney disease, not liver disease. A meta-analysis of seven trials in dialysis patients found acupuncture relieved uremic pruritus more than conventional treatment.^[9] The cause of itch differs in cholestasis, so this does not show a benefit in PBC. For dry mouth, a systematic review of 10 trials found the studies inconclusive and of low quality.^[10]

How acupuncture may work

We know of no research on how acupuncture might act in PBC, and none showing that acupuncture changes bile duct damage, liver enzymes or the course of the disease.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at selected points, typically left in place for about 20 to 40 minutes. A course usually involves several visits, with a reassessment to see whether symptoms are changing.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture). People with advanced liver disease may bruise or bleed more easily, so please share your latest blood tests.

Ayurvedic medicine as supportive care in Primary Biliary Cholangitis

The Ayurvedic view

Ayurveda has no classical name for PBC. Traditional practitioners describe chronic liver and bile problems in terms of Pitta (the principle linked with heat, digestion and bile) and weakened digestive fire (agni), with itching and heat sometimes read as excess Pitta. These are traditional explanatory frameworks, not biomedical diagnoses.

Therapies that may be used

Care is individualized and, within a supportive role, may include:

• Diet and daily routine, such as regular meals, cooling foods and steady sleep hours, kept consistent with advice from your physician or dietitian
• Gentle oil massage and relaxation or breathing practices for stress and sleep
• A herbal preparation applied to the skin may be considered for dry or irritated skin, as part of transdermal medication therapy; no research shows that it eases cholestatic itch

Panchakarma cleansing procedures are not appropriate for people with significant liver disease, and are also unsuitable during pregnancy, acute illness or frailty. We do not use them to treat PBC.

What the research shows

We found no clinical trials or systematic reviews of Ayurvedic medicine, Panchakarma or Ayurvedic herbs in PBC. The evidence is therefore none, and we do not claim that any Ayurvedic therapy affects the disease.

The research that exists concerns safety. About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[12] Ashwagandha, widely used in Ayurveda, has been linked to liver injury, often a cholestatic pattern. In an Indian case series of eight people, five had underlying chronic liver disease, and three of them developed acute-on-chronic liver failure and died.^[13]

Herbal medicine as supportive care in Primary Biliary Cholangitis

Herbs and formulas that have been studied

Laboratory and review articles describe a number of Chinese herbs and formulas that may affect liver inflammation and the gut microbiome in liver disease generally, but these are early findings and not tests in people with PBC.^[14] We did not find a clinical trial of any herb in PBC. Any herb we discussed would be chosen individually by a qualified practitioner and only after your liver specialist has been told.

What the research shows

There is no clinical evidence that herbal medicine treats PBC or relieves its symptoms. The review of Chinese medicine in liver disease is based on laboratory and animal work, and it does not show that these preparations help people with PBC.^[14]

Safety and herb-drug interactions

Safety is the main concern with herbs in PBC, because the liver is the organ already affected. Herbal and dietary supplements now account for about 20% of drug-induced liver injury cases in the United States, and the culprit ingredient is often hard to identify.^[15] Turmeric has been tied to severe liver injury in a case series from the US Drug-Induced Liver Injury Network, including one death from acute liver failure.^[16] A review of recent literature lists ashwagandha and products from Chinese and Ayurvedic traditions among those reported to injure the liver.^[17]

Herbs can also interact with prescribed medicines, including anticoagulants and drugs processed by the liver.^[18] Many herbs and supplements change the effect of warfarin.^[19] Because of these risks, we would not recommend herbal products on our own for PBC, and we ask you to check any herb with your liver specialist first. Tell us if you are pregnant or breastfeeding, or have cirrhosis or kidney disease.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine would describe long-standing liver and bile problems with patterns such as liver qi stagnation or damp-heat, and Ayurveda would speak of Pitta imbalance and impaired agni. Researchers studying PBC use different terms: immune attack on bile duct cells, impaired bile flow, and changes in the gut microbiome.^[2]

Some reviews link traditional herbal formulas to effects on the gut microbiome in liver disease, but this is laboratory-based and not shown in PBC.^[14] No study has shown that a traditional pattern corresponds to a specific biological process in PBC.

How this care fits with your medical care

PBC needs a physician's care, usually from a hepatologist or gastroenterologist. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. We do not diagnose or monitor PBC, and we do not change prescribed drugs.

Keep taking ursodeoxycholic acid and any other prescribed medicine, and keep your scheduled blood tests and imaging. Please bring your diagnosis, recent liver test results, a full list of medicines and supplements, and any recommendations from your liver specialist. New or worsening symptoms should be reported to your physician.

When to seek urgent medical care

Some symptoms may signal serious complications of liver disease and need prompt medical assessment.^[1]

• Yellowing of the skin or eyes that is new or worsening
• Vomiting blood or passing black, tarry stools
• Confusion, unusual sleepiness or marked changes in behavior
• Rapid swelling of the abdomen or legs
• Fever with abdominal pain or chills
• Itching that is severe enough to stop you sleeping or function, which your physician should know about

If you vomit blood, pass black stools, become confused, or feel seriously unwell, call 911 or go to the nearest emergency department.