027).58 This is the first study to suggest that therapy may actually impact the natural history of the disease. More recently, Gluck et

al. described a 20 year experience with endoscopic therapy for 84 symptomatic patients with PSC.59 Similar to the Baluyut study, observed patient survival was higher than expected by the Mayo Risk Score.59 All therapeutic endoscopy comes with risk. In the two largest reported series of patients with long follow-up, the risk of complications was 7.3%–20%. The complications were mild without need for surgical intervention.58, 59 The most common complications were pancreatitis, cholangitis, biliary tract perforation and hemorrhage. Focal Autophagy inhibitor nmr biliary tract obstruction, whether benign or malignant, has been the primary indication for the nontransplant surgical management of PSC. Despite limitations of the accuracy of current diagnostic modalities for malignancy in buy Metformin PSC, diagnostic laparotomy has little clinical value. The rationale for surgical management in PSC is bypass of an obstruction caused by a dominant stricture. Non-transplant surgical approaches include biliary bypass by cholangio-enterostomy or resection of the extrahepatic biliary stricture and Roux

Y hepaticojejunostomy.60, 61 Biliary bypass alone has been employed infrequently because dominant strictures are typically hilar. Moreover, the intrahepatic ducts are variably involved which limits the access and quality of these ducts for bypass.60 Florfenicol Biliary bypass has no role in PSC patients with cirrhosis. Extrahepatic

bile duct resection and Roux Y hepaticojejunostomy with or without stenting for dominant strictures is controversial.53, 61 Current evidence suggests that selected patients with non-cirrhotic stage PSC have an overall survival of 83% at 5 years and 60% at 10 years and a readmission free rate from cholangitis of 57% at 3 years for such an approach.62 Bilirubin levels > 2 mg/dL and cirrhosis are associated with decreased survival. No data regarding surgical management have shown that either bypass or resection of a dominant stricture affect natural history or disease progression. Most patients, who have not had biliary tree instrumented, have negative microbial bile cultures.63, 64 However, dominant strictures can induce stagnation of bile resulting in bacterial colonization and secondary cholangitis. This can be the first presentation of the disease occurring in 6.1% of PSC patients in one recent study.65 Furthermore, severe recurrent cholangitis may play a role in the progression of the disease. The relevance of a bile duct stricture was demonstrated by documenting bacterial infection of the bile in 15 out of 37 PSC patients (40.5%) with a dominant stricture but not in the absence of such stenosis; short-course antibiotic treatment proved not very effective in eradicating bacteria from the bile ducts of patients with dominant strictures.